Opioids not superior to nonopioid analgesics for back pain, hip or knee osteoarthritis

There was no significant difference between groups in pain-related function, and while
pain intensity was significantly better in the nonopioid group, the result did not
reach a clinically predetermined level of importance.

Opioids were not superior to nonopioid drugs for improving function related to severe
chronic back pain or hip or knee osteoarthritis pain, a study found.

Both opioid and nonopioid medication interventions followed a treat-to-target strategy
aiming for improved pain and function. In the opioid group, the first step was immediate-release
morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first
step was acetaminophen (paracetamol) or an NSAID. Patient response dictated when medications
were changed, added, or adjusted.

The primary outcome was pain-related function measured by the Brief Pain Inventory
(BPI) interference scale over 12 months. The main secondary outcome was pain intensity
on the BPI severity scale. BPI scales ranged from 0 to 10, with higher scores signaling
worse function or pain intensity. A 1-point improvement was clinically important.
The primary adverse outcome was medication-related symptoms measured by a patient-reported
checklist ranging from 0 to 19. Results were published in the March 6 JAMA.

There was no significant difference between groups in pain-related function over 12
months (overall P=0.58), with a mean 12-month BPI interference score of 3.4 for the opioid group and
3.3 for the nonopioid group (difference, 0.1; 95% CI, −0.5 to 0.7). Pain intensity
was significantly better in the nonopioid group over 12 months (overall P=0.03), with a mean 12-month BPI severity score of 4.0 for the opioid group and 3.5
for the nonopioid group (difference, 0.5; 95% CI, 0.0 to 1.0). The researchers noted
that this was less than the minimal clinically important difference of 1. Adverse
medication-related symptoms were significantly more common in the opioid group over
12 months (overall P=0.03). Mean medication-related symptoms at 12 months were 1.8 in the opioid group
and 0.9 in the nonopioid group (difference, 0.9; 95% CI, 0.3 to 1.5).

The results do not support initiation of opioid therapy for moderate to severe chronic
back pain or hip or knee osteoarthritis pain, the authors noted. “Opioids caused
significantly more medication-related adverse symptoms than nonopioid medications,”
the authors wrote. “Overall, opioids did not demonstrate any advantage over
nonopioid medications that could potentially outweigh their greater risk of harms.”

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